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Home My WebLink About15166 (20)K:3 r 0 CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190 (909) 860-.3195 Fax (909) 861-3117 BUILDING PERMIT APPLICATION JOBSITE ADDRESS arlA- APN LOT TRACT OWNER ADDRESS LL e _/ CITY ZIP /7 TEL.0 - 66( APPLICANT TEL. CONTRACTOR (fnaii/,tS v �� ADDRESS 5 /a- 15,. 4--f-S4-f-2 CITY a vii &, ..t, ZIP!a)cc'f TEL. 7346'6 ARCH/ENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION I HEREBY AFRFW UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSE LAW FORTHE FOLLOWING REASON (SEC. 7031.E BUSINESSAND PROFESSIONS CODE: ANY CITY OR. COUNTY ICH REOUIRESAPERMrrTO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIR ANYSTRUC- TURE. PR TO 1T3 ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT 7 HE OR SHE S LICENSED PURSUANT TO THE PROVISIONS 7HE CONTRACTORS LI- CENSE LAW ( TER 9 (COMMENCING WITH SEC`nOI 7000) OF DI OF T USINESS AND PRO- FESSgNSCODE) TMATHE OR SHE IS EXEMPTTHEREFROM EBASIS FOR THE ALLEGED E%EMP• TXNI. ANY VIOAT F SECTION 7031.5 BYANYAPPLiCA OR APERMIT SUBJECTS THE APPLICANTTO ACML PENALTY OF MORE THAN FIVE HUNDRED LABS (SSDD).): ❑I,ASOWN£ROF PROPERTY, OR MYE OYEES WITH WAGESAS THEIR SOLE COMPENSATION, WILL DO THE WO AND STRUCTURE T INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSI- NESS AND PROFESSIONS THE RACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDSORIMP EREON, AND WHO DOES SUCH WORK HIMSELFOR HERSELF OR 7HRWGH HIS OR HER OWN EMP PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE. IF HO THE G OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COM PLE. TqN, THE OWNER-BUILDE HAVE THE B OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PUR EOF SALE). D I, AS OWNER OF -PROPERTY, AM EXCLUSIVELY CO WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7004, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI- -.CENSE LAW DOES NOTAPPLY TOAN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITHACONTRACTOR(S)LICENSED PURSUANT TO TNECDNTRAC- TORS LICENSE LAW.). ❑ 1 AM EXEMPT UNDER SEC. B. & P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS IN FULL FOR AND EFFECT. /G, ) LICENSE CLASS - S �' _LIC. NO. LIW-_46' �"_4 DATE C� �7—c1rJ _ coNrRAcroR Yamu 11fQ)S Gbit `) WORKERS' COMPENSATION DECLARATION I HEREBYAFFiRM UNDER PENALTY OF PENURY ONE OF THE FOLLOWING DECLARATIONS: _ I HAVE AND WILL MAINTAIN ACERTfFICATE OF CONSENTTO SELF -INSURE FOR WORKERS' COMPENSATION, AS PROVIDED BY SECTION 3700 0E THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERSQOMPENS �jO�r�! INSUItANCE CARRIER AND POLICY NUMBER ARE: CARRIER �ei�tM, t%,1G"'� POLICY NUMBEfly�.�l gMSWnON NEEDnoTBECDnuLOMOF7HE PEFIW IS FORQNERXDRED WU ARS ($100) ORLESS)... I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, i SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS COMPENSATION LAWS OF CALIFORNIA. AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS COMPENSATON PROVISION OF SECTION 370D OF THE LABOR CODE,1 SHALL FORTHWITH COMPLY WITH THOSE Pt1OVI S. - I= DATE: APPLICANT. i 1_ WARNING FAILURE TO SECURE WORKER3'COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE _ SURJECTAN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UPTO ONE HUNDRED THOUSAND DOLLARS (6100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN I` SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. - CONSTRUCTION LENDING AGENCY i_ I HEREBY AFFIRM UNDER PENALTY OF PENURY THAT THERE IS ACONSTRUCTION LENDING AGENCY FDRTHE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097, CIV. C.). L LENDERS NAME ---- LENDERSADDRESS CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECI 1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING jCONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED P PER FOR INSPECTION PURPOSES. J 1 1^ G i V NAMET01 16 SIG W UR FPERMITTEE DATE LI) PRESS FIRMLY APPLICATION •��d PERMITC y� P/C DATE NUMBER �..JJ # ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDEISIDE STREET :1 RW ❑ SIDE ❑ PROPOSED USE NO. DWEL. NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREA/VALUATION SFR/ADD/REM Garage/Carport W Patio/Deck - W LL POOUSpa Z Re -Roof Commercial - m Valuation ADJ.AREA QUANTITY DESCRIPTION FEE - I'�ilUC-�1� � U LU W W 0 Z J 0- Q U Z Q M W CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL - INSPECTION FEE '_ISSUANCE SMTP —--.t—'�_--- ENERGY P/C 1` ENERGY PERMIT �A - RETENTION FEE: PRE -ALT FEE: ljt TOTAL FEES COMMENTS RECPT. NO.PAID BY VALIDATION WHITE Department Copy YELLOW—Finance Copy. PINK—Assessor Copy,. UULUrNhUu—rae copy, Unccrv—Applicants �opy